Thursday, December 04, 2008

Dysphagia in association with Thoracoabdominal aneurysm of the Aorta

Thoracoabdominal aneuryms (TAAA)which are close to esophagus may produce extrinsic compression of esophagus. It will be seen as a smooth bulge during the
during the endoscopy. Manometric studies were found to be abnormal in these patients. In this endoscopic photograph (see the attached image) the mucosal swelling and ulceration is seen near the site of extrinsic compression. Endoscopic ultrasonography has shown gas bubbles in the wall of the esophagus. Patient was able to swallow liquids only. Such types of comression of esophagus was managed some times by medical meaures in elderly woman (>84 years) successfully. But it would need attention and intervention to releive the compression in the youger and middle aged people. We have recently managed another patient with absolute dysphagia associated with TAAA. He required Total parenteral nutrition before the Endovascular repair of the TAAA. His ability to swallow improved after the Endorepair with Endograft due to the relief of pressure over the esophagus by the TAAA.
By
Pinjala R K

Sunday, November 23, 2008


Affect of the “Tibial-arterial disease”
on the outcomes in leg vascular disease patients

The lower limb arterial system is divided in to 3 segments for better understanding of the disease and also for planning various therapeutic options. Aorto-iliac, Femoro-popliteal and Tibio-peroneal diseases are three zones. However the quantity of the disease is not measured accurately for the routine clinical purposes. Therefore comparing the out comes of procedures performed on patients with different degrees of functionally active and mechanical disease. The failure rates of infra popliteal revascularization are high across all the countries irrespective of their methods of revascularization.The determining factors seem to be diabetes and history of prior tissue loss or gangrenous changes.In the routine clinical practice it is important to grade the tibial vessel disease which is often missed. In the post operative period one tries to look for the Doppler signals and palpable pulses which may be or may not be good enough for the relief of symptoms over a long period of time.


In a recent paper published -Multivariable analysis demonstrated tobacco use, renal disease, diabetes, and tissue loss are all predictors of patency loss, while only diabetes and tissue loss were associated with greater limb loss. There was no difference in patency rates irrespective of location of Trans Atlantic Inter-Societal Consensus (TASC) classification, vessel treated (femoral vs tibial), or degree of stenosis (occluded vs stenotic). Also, multiple vessels treated in the same patients had no affect on patency. The mean ankle brachial index (ABI) pre-op was 0.57 +/- 0.19, and this increased to 0.81 +/- 0.21 (P < .001) at 30 days post-op. CONCLUSION: Lower extremity atherectomy procedures with the SilverHawk device are safe and effective means in improving symptoms. However, there is decreased durability and significant patency and limb loss over time. Diabetes, renal disease, tobacco use, and tissue loss are all associated with inferior outcomes.


Reference:

Sarac TP et al, J Vasc Surg. 2008 Oct; 48(4):885-90

Midterm outcome predictors for lower extremity atherectomy procedures. Sarc TP et al
Department of Vascular Surgery, The Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.


Atherectomy in the lower limb arteries
Is there a future for this procedure in getting better limb salvage ?

Saturday, November 22, 2008


Laparoscopic Vascular injuries at the level of Iliac artery (Pelvis) can be life threatening due to pelvic and retroperitoneal bleeding.

In the recent past 3 patients with iliac artery injury were referred from the peripheral hospitals for management. In these there has been difficulty in sending to the concerned specialist centers very late due to logistics. In all the three patients an attempt was made by the general surgeons to control the bleeding but it also resulted in systemic problems and distal limb ischemia (Acute). In one patient there was iliac vein thrombosis in addtion to the arterial injury. One patients required femoro-femoral corss over graft ( tubectomy patient) , 2nd patient required direct repair of the iliac artery ( plus appendicectomy) and 3rd patient required Aortofemoral bypass (+Tuberculous adhesiolysis). In all the three patients the limb was salvaged.
Large Venous Malformations in the Neck -

Are they curable with the available therapies?


Open surgeries, endovascular therapies and other plastic surgical procedures?


Large Venous malformations in the Head neck region are associated with complex hemodynamics and anatomy. Imaging these lesions adequately is difficult and planning interventions in multiple stages may be expensive and tiring to the family and providers. In addition the procedures are associated with hidden complications. Probably one would like to hear about the possibility of genetic therapies for such large lesions with intra thoracic ramifications and communications with other large veins in the head and neck region.
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Sunday, November 16, 2008

Vascular Malformations in the thigh and lower extremities
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Vascular malformations would require detailed evaluation and planning to remove of them. It is possible through multiple approaches such as endovascular, operative vascular and plastic surgical reconstructions after excisions.

It involves repeated, investigations and multiple visits to the hospital, blood transfusions. Surigcal excision after a previous failed attempt is much more difficult due to the adhesions and neovascularization. This is the photograph of such patient with a large thigh AVM with aneurysmal component of the AV communication. The cost of management in such cases will be always more than what is expected by a common man. Adequate planning for the finances and explaining the patients about the risks including the limb loss is essential part of the treatment.
Pinjala R K
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Saturday, November 15, 2008


Non-healing Ischemic Ulcer on the Dorsum of Foot

Fig: Non healing ulcer

This type of ulcers are difficult to manage and fail to heal with the usual measures such as local wound care and improvement of micro circulation (drugs). This patient (58 yrs) had Femoro-popliteal bypass in the past (10 yrs back) and that was blocked in the due course of time with development of tibial vessel disease. He received Injection Heparin, PGE-1 infusion, antiplatelet drugs and statins. It failed to heal and rest pain persisted ( 2 years). The tibial vessels were not suitable for any type of distal bypass. The heal of the foot is healthy and so are the toes as seen the photograph.

1. What further treatment can be offered in this patient for healing of ulcer and relief of pain?
2. Would like to consider any type of amputations?
3. Any special Endovascular therapies?

By Pinjala R K

Chronic wounds and facilitating their healing with Growth factors-

EGF, PDGF in non healing ulcers.

Growth factors such as EGF ( Epidermal growth factor), PDGF ( platelet derived growth factor) have been found to be useful in improving the wound healing. These are available in gel forms to applied after controlling the wound infections. Arterial ischemia, neuropathy, venous insufficiency are common in those non healing ulcer to different degrees. Correction is possible in some patients but in few the correction of them is partial or may not be possible. In such cases, we need to consider the growth factors such as these to facilitate and enhance the healing rates. Probably these growth healing help in shifting wounds from one stage to the other that is from inflammatory to the proliferative and from there to the maturation phase when the native wound growth factors fail to do so, due to the underlying pathophysiological changes. In India, these two growth factors are available in the market for use and are also affordable.

by

Pinjala R K

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Thursday, November 13, 2008

Behcet's disease:

This is Brachial artery angiogram showing - total occlusion of the radial artery close to its origin. The ulnar is showing short segment of stenosis. The median interosseous artery is reformed and coursing down wards in the middle of forearm.

During surgery, the brachial artery and its bifurcation were found to be be engulfed by inflammatory tissues with excessive adhesions and edema. The tissues are fragile and the veins are dilated and thickened. The arterial wall is also fragile, thickened along with multiple dilated venules over its wall. The thinned walled collateral (neovascularization) vessels in the arterial walll are easily bruising. It is suggestive of a chronic process affecting (in elbow region) affecting brachial, radial and ulnar arteries and bifurcation. The brachial and ulnar artery were felt after the dissection and isolation of areteries with release of tight adhesive inflammatory tissues around them.

There was strong clinical suspicion of Behcet's syndrome based on the findings in this patient. He was given steroid in the peri-operative period and his clinical condition significantly improved. Through multiple incisions in the forearm and plam fasciotomies were done to release intra compartmental pressure.

Pinjala R K
15th Nov 2008
Sent from BlackBerry® on Airtel

Tuesday, November 11, 2008


VEIN GRAFTs+ SYNTHETIC GRAFTs = Composite graft
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Non availability of the long saphenous vein grafts for the long segment Femoro-popliteal bypass in the legs with distal anastomosis below the knee is common. The great saphenous vein is many times not suitable for the bypass surgery as its size is less than 4 mm in diameter in all its length and there can be branching of great saphenous vein. We do not have Indian data on the suitability of vein grafts for Femoro-popliteal bypass. We do not want to place the synthetic grafts across the knee joints due to the fear early thrombosis. Composite grafts ( half synthetic grafts and half vein grafts) are probably best suited for the Femoro-distal bypass in such cases.

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Saturday, November 08, 2008


Crush injury to shoulder / arm from Tractor wheel
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Crush injuries are usually difficult to treat when they are around the shoulder girdle and pelvic girdle. Recently a middle aged gentleman was referred to us after giving initial treatment in a local govt hospital. On examination the shoulder, upper limb was crushed, edematous, tense and infected. Clavicle and Corocoid process fracture was noted. There was occlusion of the 2nd and 3rd part of the subclavian artery. Devitalized skin (necrotic skin) around the shoulder and arm was infected. A large collection was noted in the axilla and sub pectoral region. There was significant induration around the clavicle fracture (12 days) and it was looking like phlegmon.


what should be done in such cases?

what is the expected outcome?

By
Pinjala R K
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Training in vascular surgery and a career in vascular surgery
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Peripheral vascular problems are now getting the attention after significant improvement in the cardiac care. There are few vascular surgeons and vascular surgical centers in the country. We will be requiring more number of trained doctors for taking care of the people with vascular problems. The National board of examinations has introduced 3 years course in vascular surgery in 3 centers in India. MCI is also going to start the MCh in vascular surgery in more centers soon. Nurses, technicians and other paramedical staff are needed to complete the vascular surgical services to the patients. At the same the needs of the people with arterial disorders is different from those with venous problems. Majority of the patients are now looking for the day care services and minimally invasive procedures. The hospitals have to gear up to face this challenge by providing new facilities focused around the day care for the vascular (arterial / venous) surgical patients. We hope that there is going to be bright future for those who are opting for the career in vascular surgery.

By
Pinjala RK
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What condition is this?

This patient was undergoing cardiac surgery for Atrial septal defect cardiothoracic OT. Then the Cardiac surgeon and anesthetist called for help from the vascular surgeon. The right upper limb was found to be swollen and ischemic on examination by vascular surgeon.

A small procedure was done. What could it be?

What can happen to the limb if unattended?

By
Pinjala R K

Friday, November 07, 2008

VAICON 2009 (23, 24, 25 Jan'09)

Dear friends,

It is my pleasure to invite you to attend the VAICON 2009 in Jan 2009 on 23,24,25th at Hyderabad, Fortune Manohar Hotel. Venous disease is common and we all see clinical problems related to the venous disease often in our patients. These patients with venous disease present with varicose veins, swollen legs, painful legs, recurrent ulcerations and pigmentation around the ankles. we would like to discuss these clinical problems and share our views and experiences in the coming meeting about the current methods of treating venous disease. Doctors from India, Europe, Australia and America are going to participate in this meeting and present their perspectives.we would like to meet you and welcome you. Please make it possible to attend the actively participate in this meeting and make it a successful meeting.
(Photo: A happy person after treatment at NIMS for Bilateral leg venous ulcer ( 10 yrs).

with regards

Pinjala R K
on behalf of the Organizing committee.
Call 9490295027 for more details.


Dr LRC Reddy and Dr Devendersingh are the conference coordinators.

Wednesday, November 05, 2008

Development of Tissues with structural abilities on biodegradable scaffolds!
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In recent past stem cell therapy is recognized as an important tool in the regenerative medicine. The different types of cells with functional abilities can be produced from the stem cells but the development
of tissues and organizing them as functional units is not that simple. We need different types of scaffolds for the cells to grow and produce the tissues with structural functional abilities. Probably this will be helpful in closing the congenital defect in the heart, A V- Fistulas and other types of medical problems.
Development of different types of bio-degradable scaffold to allow the cells to arrange themselves in to the tissues with structural and functional abilities. We
hope this new developement published in the On line edition of the Nature materials is going to quoted for very long time in the future with further advancement of science in the regenerative medicine.
By
Pinjala R K

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Monday, November 03, 2008

What is new in Thromboprophylaxis?
Cost-Effectiveness of Thromboprophylaxis with two different low molecular weigh heparins?
Enoxaparin vs Fondaparinux!

presented in CHEST 2008, the annual meeting of the American College of Chest Physicians.

Enoxaparin discharges had a mean total direct medical cost of $9,755 compared with $12,683 for fondaparinux discharges, for a difference of $2,928 per patient, Dr. Merli reported. After adjusting for patient and hospital characteristics, the costs associated with enoxaparin were $6,479 compared with $6,658 with fondaparinux, for a difference of $179.The cost of anticoagulant therapy was also lower for enoxaparin discharges than for fondaparinux discharges, at $130 and $163, respectively."The total adjusted medical cost savings per patient was $442 with enoxaparin compared with fondaparinux," Dr. Merli stated. "This is a significant savings, considering the number of patients treated each year for VTE prophylaxis."
"The annual cost of VTE prophylaxis is around $1.5 billion." in USA says Dr Merli.

It would be too primitive to talk about the annual cost of VTE prophylaxis in a big country like India or China based on the ACCP guide lines.In the ENDORSE study we noted that 50% of the hospitalized ( Acute care) would be requiring some form thromboprophylaxis. One can imagine that type calculations would be mind boggling for the indian pharmaceutical industry. In our country many are still of the opinion that very few can chemical thromboprophylaxis and in some situations the doctors are still hesitant to consider the chemical thromboprophylaxis. Injection Heparin ( UFH) is still used by majority when they think it is necessary due to the cost of the low molecular
Align Rightweight heparins. In India LMWH is produced by one or two companies but they are not able to compete with the international brands in many angles. The awareness for the Venous thromboembolism increased in the last 10 years but there is lot more to be done by the Indian doctors and medical companies in this direction.
Pinjala R K. Nov'08

Sunday, November 02, 2008


Newer Atherectomy devices for the SFA occlusion


Atheroscleorotic lesions in the lower limbs usually present in the late stages. TASC D lesions with poor distal run off is not uncommon in our clincal practice. When such patients are seen with gangrenous changes in the toes we have to attempt some kind of recanlaization treatements. Placement of stent or stent graft is going to be very difficult and at the same time a long segment has to be covered with 3 or more number of stents. Excimer Laser and other type of measures have not proved good enough. In the recent past we have performed Atherectomy using the silver hawk atherectomy device from the tibial artery, popliteal artery and femoral artery. Multiple long small pieces of atheroma was removed to obtain a decent lumen in the vessels from the groin up to the knee. Post precedure tha ankle pressure was 110 mm of Hg and maintained so till now that is 10 months.

This device is superior version of atherectomy devices. There different sizes to match the size of the artery that needs debulking. The chances of rupture are rare and easily that stop with compression bandages. Distal protection device was used in this patient ( spider XX) to extract distlly embolized material. There was some amount of debris after the completion of the precure in the spider X filter device. In such type of complex procedures one should be considering a protection device to avoid the complications.

This device is getting popular in certain but not yet approved in many centers for the routine clinical usuage.

Lecture given by
Prof.Pinjala R K’08
1 Nov 2008
ISVIR, Mumbai , J W Marriot Hotel.

Atherosclerotic plaque morphology and Therapeutic strategies – Medical and Endovascular.
A lecture by Prof. Pinjala R K, Dept of Vascular surgery, NIMS in ISVIR 7th Annual meeting at Mumbai, J W Marriot Hotel, on 1st Nov 2008.




Atherosclerosis of the arteries slowly progress over a period of time with small fatty streaks to complicated plaques with calcification, thrombosis or hemorrhage. In the past surgeons used to bypass the diseased segments and stayed away from the lesions so, there was probably they have felt there was limited need for understanding the morphology of these lesions but with the endovascular recanalization the interest in better understanding was rekindled among the specialists. So, we would certainly like to look at the role of different types of therapies based on the morphology of plaques to get good results with cost effectiveness.
In the recent past many new terms are used quite often by the specialists such as – Unstable plaque, plaque erosion, plaque ulceration, athero-thrombosis, intra plaque hemorrhage and heterogenous plaque. All these terms indicate that the plaque is not only causing problems due to its size (obstructive nature) but also due to the intrinsic morphology of the plaque. Necrotic lipid core (>40% of plaque content), Inflammatory cell component and thinning of the fibrous cap of plaque are three important changes associated with the unstable plaques. In given segment of atherosclerotic artery there can be distribution of stable and unstable plaques in different patterns. Suspicion, detection and imaging of the vulnerable plaques adequately is the challenge we have to pass to look at the therapeutic strategies.
Imaging of the unstable plaque or vulnerable plaque is important to understand morphology and plan the therapies. Biomarkers can only give us indirect evidence of the load of unstable plaques in a person. People with diabetes are known to have more number of vulnerable plaques in given than the non diabetic persons. The internal regulatory mechanism tries to suppress these vulnerable plaque complications to some extent for some time. Angioscopy was used in the early 80s but the images were not clear and it was cumbersome to do the (invasive) angioscopy in routine clinical practice. Intravascular ultrasound (IVUS), Optical coherence tomography are the other imaging modalities used to detect the lesions. Plaque Thermography detects the temperature differences and helps in pointing out the vulnerable plaques with slightly increased temperature. Non invasive methods are duplex scan (gray scale gradients), CT scan, MRI and PET scan were used to study the morphology of the plaques. These investigations are expensive in today’s practice and they are investigational tools for the research studies. The unstable plaque morphology has been found to be changed to stable plaque morphology by the medical therapies, at the same time preventive measures such as protection devices (thrombus retrievers) were used during the endovascular interventions.
The cumulative survival of an individual is found to be affected by the size of plaque (degree of stenosis) and morphology (heterogenous /homogenous plaques or no plaques) independently. The larger plaques (with greater stenosis) are found to be more heterogenous and obviously it indicates that have a more complex plaque morphology which has progressed over a long period of time. The PET scans could detect the (hot spots) inflamed plaques (macrophage infiltration) and they disappeared with medical therapies and corresponded with the benefits shown by the drugs such as statins.
Medical therapies are needed much before the patients arrive for the interventions of obstructive lesions. Some times it reminds me that the peptic ulcer disease presents as pyloric stenosis if it persists for long time after incomplete treated or untreated for a very long time. We then consider a gastro-jejunostomy to bypass the pyloric stenosis. Of course, some performed pyloroplasty and re-stenosis was the known complication in such patients that required re-surgeries when adequate suitable medical treatments were not available. There is some similarity here between plaque ulceration and peptic ulceration. Today we know that peptic ulcerations are linked with helicobacter pylori and adequate therapies are needed to eradicate the local infection of the gastric mucosa to cure peptic ulcer disease and at the same time prevent the re-infection. When this understanding was not there we known that some patients were subjected to major surgeries such partial gastrectomy or total gastrectomy.
The atherosclerotic plaque progression from stage 1 to advanced stages may not be incremental. Type 2 or 3 plaque may become type 5 or 6 suddenly in a person and result in sudden occlusion of vascular lumen without giving enough to develop the collaterals. So, the plaque disease needs early attention and preventive measures to make them less and less vulnerable to avoid the sudden transition of the plaques to the advanced stages.
Correction of endothelial dysfunction with statins and ACE inhibitors, correction of the prothrombotic state with antiplatelet drugs, improvement of endothelial functions by dietary regulations and exercise, diabetes control, hypertension control will benefit the patients to improve the survival, reduce the complications and improve the results of interventions or reduce the need for them in the beginning or later re-interventions. Medical management of plaques is as important as the ascertaining the luminal patency with the interventional measures.
Atherosclerosis plaque distribution in the coronary, carotid, peripheral vascular circulations is also dependent to some extent on the genetic component. Neovasculogenesis of the plaque, role of the growth factors and role of stem cells in healing of the ulcerated plaque is under investigation. The recently popularized drug eluting stents have given a new window to understand the drug delivery at the site of ulcerated plaques which can modify the plaque morphology. Probably in future we may be able to deliver drugs to early lesions through (magnetized tips) micro-catheters directed by Spiral CT (Fast) imaging guidance. Probably we may be also looking at different class of anti-inflammatory drugs which are specially designed for the vascular inflammation as it seems to be different from the other types of aseptic chronic inflammations.
In future management of vascular (occlusive) disease aims at treating the plaques before they develop complex morphology with complications/ stenosis. Similarly in the post Endovascular intervention phase strict measures will be taken to change the morphology of the neighboring the plaques and prevent their progression to maintain the results.

Prof. Pinjala R K’08

Atherosclerotic plaque morphology and therapeutic strategies.
Plaques are classifed in to different stages that is from 1 to 7. Some times they progress very fast from 1 stage to higher stage without much gap. The newer treatments should be based on the morphology of the plaques.
A lecture (text) given in ISVIR 2008, Mumbai is placed here.

Pinjala R K

Monday, October 27, 2008


VAICON 2009

23,24,25 January’09
Hyderabad-AP, India
at Hotel Fortune Manohar




Venous disorders are commonly seen as benign problems and they
are known for their chronicity and poor response to different types
of therapies available. The venous problems are usually undiagnosed,
under diagnosed, under treated at the primary levels. The
late features of venous disease such as multiple varicose veins
with leg swelling, pigmentation, ulcerations are the usual presentations
in our clinical practice. Heaviness of the legs, tightness in
the calf, claudication are often mistook for the musculoskeletal
disoders and bones, joints given attention. Recurrent attacks of the
celllulitis is another type of presentaiton in patients with chronic
venous insufficiency due to venous hypertension ( ambulatory
venous pressures more than 80 mm of Hg).

In the RELIEF study ( 300 patients) from India it was observed
that 80% of the patients with CVI were not given any form of
treatment such as compression stockings, crepebandages,
phlbotonic drugs or other therapies. This clearly indicates that
there is an opportunity increase the awareness of the venous
disorders and encourage to prevent Chronic venous insufficiency
syndrome to progression from the early stages to the advanced
stages where they may require surgeries for improving the condition
and facilitate the healing of the venous ulcerations.

Prof. Pinjala R K’08
VAICON- 2009


Deep vein thrombosis
Acute DVT
Chronic DVT
Reccurrent DVT
Pulmonary Embolism
Post operative patients
Medical patients
Post traumatic
Venous Ulcers
Wound healing
Cost effective therapy
Diabetes / venous
Chronic
Venous insufficiency
Medical therapies
Surgical therapies
Varicose veins
Primary
Secondary
Recurrent
Thromboprophylaxis
Medical patients
Surgical patients
Cancer patients
Recent advances
Varicose veins
Venous thrombosis
Quality of Life
Venous Association of India (VAI)



Wednesday, October 22, 2008

Sclerotherapy for varicose veins vs conventional surgery?
Is there any comparision between these modes of therapies, are we comparing the two different therapies which are meant for two stages of the venous disease? give your comments! Soon we will be posting our views about these two methods of therapies.
Pinjala RK